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SAN JOAQU_-. COUNTY ENVIRONMENTAL HEALT"EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# cSERVICE REQUEST# <br /> ✓ �1 � <br /> A-- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME D3 -6 llnnM, rt C,0, t �h r ^ J <br /> SITE ADDRESS 12 'Yrt M- „ /) 1�' ' %/ ` <br /> Street Number Direction ►Y l r/l� Street Name �/6`Cit' Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 171/1 I '5r/'r� <br /> Street Number Street Name 1 <br /> CITY n^'A STATE ZIP q S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> WD— 011t?Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> VLv <br /> rA vn„/ tC /iy /►,� CHECK If BILLINGADDRESSE] <br /> BUSINESS NAME rte\' Vv ��e, ;��V`' � PHONE# EXT. <br /> W \0 4l 0-GlL 0Z <br /> HOME Or MAILING ADDRESS-6\4 FAX# <br /> CITY <Dy� STATEC/� ZIP QA al -?�o S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> � '�J h <br /> APPLICANT'S SIGNATURE: " l\ W(V+�-� ( c9'` DATE: 11 - (D c�o7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I"V b li \de wt <br /> COMMENTS: <br /> r <br /> 8AN 14A <br /> R 10 20 <br /> �OUM� LN <br /> TM <br /> DE 1� <br /> ACCEPTED BY: ,�/( ,�\ _n _n 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: C .v `�'� EMPLOYEE#: DATE: W <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: O3 <br /> Fee Amount: K `S-Z — Amount Paid �CI).— Payment Date P 2� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />